European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> An Overlapping Case of Miller Fisher Syndrome and the Pharyngeal-Cervical-Brachial Variant of Guillain-Barré Syndrome <p>A 55 years-old Caucasian male presented initially in the emergency room reporting myalgia, chills and fever. Physical exam and laboratory tests were unremarkable and he was discharged with symptomatic care. He returned to our ER two weeks later reporting dizziness, loss of balance, blurred vision, mild dysarthria and bilateral hand paresthesia. On examination he presented complete bilateral ophthalmoplegia, mild dysarthria, left finger-to-nose dysmetria, ataxia, areflexia and bilateral hand hypoesthesia without fever. Blood tests and head computed tomography were normal. The patient was admitted to the Internal Medicine department. On second day inwards the patient presented dysphagia. Head magnetic resonance angiogram showed no signs of ischemia or vascular disease and a lumbar puncture was performed but no pleocytosis, albumin-cytological dissociation or hypoglycorrhachia was present. Despite the normal results we suspected of a Guillain–Barré syndrome variant, and started treatment with intravenous immunoglobulin (IVIG) in a dose of 400mg per kilogram and continued for five days with immediate neurological improvement. We present a rare&nbsp;overlapping&nbsp;case of&nbsp;Miller Fisher&nbsp;syndrome and Pharyngeal-Cervical-Brachial variant of Guillain–Barré syndrome.</p> Hélio Martins Joana Mendonça David Paiva Carlos Fernandes Jorge Cotter ##submission.copyrightStatement## 2020-01-27 2020-01-27 10.12890/2020_001387 A Mesothelial Inclusion Cyst Presenting in a 40-Year-Old Woman as Abdominal Pain and Bloating – A Rare Diagnosis <p>Cystic mesotheliomas (also called mesothelial inclusion cysts) are rare benign neoplasms that occur more often in young women. Symptoms are usually non-specific, demanding a thorough work-up. We report a case of a 40-year-old female patient with 2 prior caesarean sections presenting with a 3-month history of abdominal pain. Laboratory tests revealed microcytic hypochromic anaemia and an elevated tumour marker CA-125. An investigation identified a large cystic abdominal mass, mostly in the left side of the abdomen. A laparotomy was performed with total resection of the lesion. Histological assessment resulted in a diagnosis of a mesothelial inclusion cyst. The patient had no recurrence after 3 years.</p> Sonia Canadas Rita Fernandes Hugo Almeida João Santiago Correia ##submission.copyrightStatement## 2020-01-24 2020-01-24 10.12890/2020_001415 Brugada Phenocopy Induced by a Lethal Methanol Intoxication <p>Brugada phenocopies (BrP) are clinical entities that present with an ECG pattern identical to either the type 1 or type 2 Brugada pattern without true congenital Brugada syndrome. This ECG pattern is associated with an identifiable condition and normalizes upon resolution or treatment of the underlying cause. We present a case of a 54-year-old man with extreme metabolic acidosis, hyperkalaemia and a Brugada type 1 ECG pattern in the setting of a suicidal methanol (MeOH) poisoning. Upon correction of these metabolic derangements with bicarbonate infusions and continuous veno-venous haemodiafiltration (CVVH), the Brugada type 1 ECG pattern normalized. Unfortunately, the patient developed signs of cerebral herniation followed by brain death and died on the first day of ICU admission.</p> Monterrubio-Villar Jesús Llinares-Moya David ##submission.copyrightStatement## 2020-01-23 2020-01-23 10.12890/2020_001374 A Symptomatic Pneumocephalus as a Complication of Lumbar Epidural Anaesthesia <p><em>Introduction:</em> Lumbar epidural anaesthesia is a commonly used technique for analgesia during labour. One of the rare complications of this technique is pneumocephalus. <br> <em>Case description:</em> We report the case of a 35-year-old female admitted to the Emergency Department with severe headache associated with fast head movements. Five days previously she had a eutocic delivery and lumbar epidural anaesthesia was performed. A brain computed tomography (CT) scan showed pneumocephalus and she was admitted to the hospital ward. A brain CT scan on the fourth day of hospitalization showed resolution of ventricular pneumocephalus. <br> <em>Discussion:</em> The most frequently occurring symptom with pneumocephalus is headache associated with fast brain motion resulting from air injection and meningeal irritation. When there is clinical suspicion of pneumocephalus, a brain CT scan should be performed for the diagnosis.</p> Ana Filipa Pires Teresa Martins Mendes Ana Areia Reis Ana Ferreira Pacheco Vítor Fagundes Mari Mesquita ##submission.copyrightStatement## 2020-01-22 2020-01-22 10.12890/2020_001425 She Has The Blues: An Unusual Case of Copper Sulphate Intoxication <p><em>Background: </em>Copper is an essential trace element of the human body. However, it is related to many diseases. Copper intoxication is not common in Western countries, but needs to be rapidly recognised because of its high lethality.<br> <em>Case presentation:</em> We report the case of a 40-year-old woman who presented to the emergency department after performing intrarectal administration of a blue powder sent from Cameroon by her family, in the belief that this would help her to get pregnant. Her evolution was complicated by multiorgan failure and the unusual circumstances. The diagnosis was suspected on the basis of the clinical presentation and the colour of the powder, and confirmed by blood dosage and toxicological analysis of the powder. She underwent symptomatic treatment, and the outcome was progressively favourable, apart from persistent chronic renal failure with dependence on dialysis. <br> <em>Conclusion:</em> Copper intoxications are rare but severe. Laboratory diagnosis of the condition is not an issue; the difficulty is suspecting it and quickly initiating chelation treatment associated with symptomatic treatments.</p> Aurore Moussiegt Luis Ferreira Jérome Aboab Daniel Silva ##submission.copyrightStatement## 2020-01-21 2020-01-21 10.12890/2020_001394 Tuberculoid Leprosy with External Jugular Vein Thrombosis: A Case Report and Literature Review <p>Thrombotic disease represents a rare manifestation of leprosy. In this study, we report the case of an external jugular vein thrombosis associated with tuberculoid leprosy in a 23-year-old male patient. The patient presented with a 3-month history of painful cord-like swelling on the left side of the neck and a nearly 3-week history of skin lesions on the left cheek and right leg. Physical examination revealed cord-like, tender swelling on the left lateral aspect of the neck overlying the sternocleidomastoid muscle, and a hypopigmented, hypoaesthetic 6×7 cm lesion with an irregular margin on the left cheek. A Doppler ultrasound examination of the jugular vein showed thrombosis of the left external jugular vein. Three-dimensional reconstruction of the computed tomography scan showed the enlarged and enhanced left external jugular vein, as well as 1 of its tributaries, and the thickened skin patch. A skin punch biopsy from the left cheek lesion revealed granulomatous inflammation with occasional peri-adnexal granulomas, consistent with the clinical impression of tuberculoid leprosy. A diagnosis of leprosy with external jugular vein thrombosis was established. Anticoagulation therapy was initiated, and the patient was referred to an infectious disease clinic for treatment with anti-leprosy medications.</p> Ali Ibrahim Rahil Ahmed Osman Mohamed Magdi Mohamed Eid Sara Kanbour Ahmed Mahfouz ##submission.copyrightStatement## 2020-01-20 2020-01-20 10.12890/2020_001302 Severe Acute Liver Injury Related to Heat Stroke <p>Heat stroke (HS) is a life-threatening condition characterized by hyperthermia and multiple organ failure. Mild to moderate hepatocellular injury is a well-documented complication but severe liver injury and acute liver failure are rare. There are neither established criteria nor optimal timing for liver transplantation and conservative management seems to be the cornerstone treatment. The authors report a case of a patient with severe liver injury related to HS who recovered completely under conservative treatment.</p> Fani Ribeiro Mário Bibi Marta Pereira Sofia Ferreira Helena Pessegueiro Rui Araújo ##submission.copyrightStatement## 2020-01-17 2020-01-17 10.12890/2020_001382 Behçet’s Disease and Tuberculosis: A Complex Relationship <p>Behçet’s disease (BD) is a systemic vasculitis characterized by recurrent orogenital ulceration and several systemic manifestations (such as gastrointestinal involvement, vascular disease or arthritis). The pathogenesis is still unknown but the trigger role of certain pathogens such as <em>Mycobacterium tuberculosis</em> is well documented. Furthermore, patients with BD are more susceptible to tuberculosis due to immunity defects. Here, we describe the case of a 70-year-old woman with a history of recurrent oral aphthae and inflammatory arthritis presenting with extensive thrombosis of left upper limb major veins, a positive HLA B51 genotype and colon ulceration; hence, BD diagnosis was made after excluding other causes. Simultaneously, the patient had cutaneous abscesses not associated with immunosuppressive therapy with continuous development, and after recurrent negative tuberculosis work-up, <em>M. tuberculosis</em> was isolated in an abscess culture.</p> Sara Mendonça Freitas Joana Silva Marques Ana Grilo Rodolfo Gomes Fernando Martos Gonçalves ##submission.copyrightStatement## 2020-01-16 2020-01-16 10.12890/2020_001354 Panitumumab-Induced Eruptive Seborrhoeic Keratosis in a Patient with Metastatic Colorectal Cancer <p><em>Objectives:</em> Agents targeting the epidermal growth factor receptor (EGFR)-mediated signalling pathway are increasingly being used for the treatment of advanced lung, pancreatic, colorectal and head and neck cancers.<br> <em>Case presentation:</em> Here, we report the first case of eruptive seborrhoeic keratosis following panitumumab treatment, an anti-EGFR monoclonal antibody, in a 73-year-old patient with stage 4 (IV) colorectal cancer with hepatic metastasis. <br> <em>Conclusion:</em> While panitumumab is an emerging therapy for RAS wild-type metastatic colorectal cancer, physicians should consider panitumumab as a potential cause of eruptive seborrhoeic keratosis.</p> Dimitra Koumaki Sotirios Boumpoucheropoulos Vasiliki Koumaki Alexander Katoulis Georgia Pappas Aikaterini Mantaka Konstantinos Krasagakis ##submission.copyrightStatement## 2020-01-15 2020-01-15 10.12890/2020_001411 Ozone Therapy for Oral Palatal Ulcer in a Leukaemic Patient <p>Chemotherapy usually causes complications affecting several tissues such as oral mucosa. In this case report, a soft palate oral ulcer caused by chemotherapy was treated by ozone gas. This kind of treatment is known for its antimicrobial, regenerative and analgesic proprieties. The results show a complete resolution of the lesion within 2 weeks of treatment. Ozone therapy demonstrates greater effectiveness with respect to this kind of oral lesion compared to traditional therapy. Considering this evidence, ozone therapy should be considered as a useful tool for the adjuvant therapy of oral complications in oncologic patients.</p> Giacomo Oldoini Giulia Ricci Frabattista Maria Saragoni Saverio Cosola Enrica Giammarinaro Anna Maria Genovesi Simone Marconcini ##submission.copyrightStatement## 2020-01-14 2020-01-14 10.12890/2020_001406